BackgroundMultidrug-resistant Gram-negative bacteria (MDR-GNB) present a significant and escalating hazard to healthcare globally. Context-specific interventions have been implemented for the prevention and control of MDR-GNB in several healthcare facilities. The objective of this study was to implement and evaluate the effectiveness of evidence-based interventions in the incidence and dissemination of MDR-GNB.MethodsAcinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli) were collected prospectively. Genomic fingerprinting was performed on isolates using enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR) to determine clonality and establish a link between different strains within and between the hospital wards/units. In the second phase, targeted interventions were implemented in the adult intensive care unit (ICU) based on previously determined risk factors and included the education of healthcare workers on hand hygiene, disinfection of patients’ surrounding, daily chlorhexidine baths, and disinfection rooms on discharge with hydrogen peroxide fogging after MDR-GNB patients were discharged. An antibiotic restriction protocol was simultaneously implemented as part of the hospital antibiotic stewardship program. In the third phase, the effectiveness of the interventions was evaluated by comparing the incidence rate and clonality (using ERIC-PCR genetic fingerprints) of MDR-GNB before and after the intervention.This was a pre-and post-intervention study conducted in three phases at King Abdulaziz Medical City Jeddah, Saudi Arabia. During Phase-1, the data on each of the four MDR-GNB (ResultsA. baumannii strains appear to be circulating within the ICU environment with reduced frequency in Phase-2 and Phase-3 compared to Phase-1.A significant reduction of MDR-GNB was observed in Phase-2 and Phase-3 compared with Phase-1. The mean incidence rate of MDR-GNB per 1000 patient days in Phase-1 (pre-intervention) was 11.08/1000, followed by 6.07 and 3.54/1000 in Phase-2 and Phase-3, respectively. A statistically significant reduction was observed in the incidence rate of MDR-GNB in the adult ICU (P=0.007), whereas no statistically significant decrease (P=0.419) was observed in areas other than the adult ICU. Two Conclusion There was a significant reduction in the incidence of MDR-GNB in the adult ICU due to the successful implementation of both infection control and stewardship interventions, albeit challenging to ascertain the relative contribution of each. Acinetobacter baumannii (A. baumannii), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa), and Escherichia coli (E. Coli) [Antibiotic resistance is among the leading global health problems facing modern medicine . ResistaE. Coli) . MultidrE. Coli) ,5.Several risk factors could be associated with an increased incidence of MDR-GNB, including antibiotic overuse and misuse, lack of compliance to and/or sub-optimal infection prevention and control (IPC) principles, unskilled healthcare workers, an unhygienic environment that facilitate the spread of resistant organisms and deficient antibiotic use, and resistance surveillance systems . AntimicDespite the inclusion of IPC and antibiotic stewardship in the Saudi Arabian strategic plan to mitigate the antibiotic resistance challenge , there iThe study's objective was to assess the impact of evidence-based interventions on the incidence and dissemination of common MDR-GNB in an adult ICU at King Abdulaziz Medical City, Jeddah, Saudi Arabia.Ethical approval The study was approved by the Institutional Review Board (IRB) at King Abdulaziz Medical City in Saudi Arabia (RJ13/032/J) and the Biomedical Research Ethics Committee (BREC) at the University of Kwazulu-Natal (BE279/13). All data were anonymously collected and interpreted. Additionally, all patients signed a general consent form at the time of hospital admission as part of the hospital policy.Study design and setting The study was conducted at King Abdulaziz Medical City Jeddah (KAMC-JD) in Saudi Arabia. KAMC-JD is an over 500-bed tertiary care hospital serving the National Guards and their eligible dependents in the Western Region of Saudi Arabia. Four adult ICUs house combined medical and surgical patients with a capacity of 28 beds. This was a pre-and post-intervention study conducted over 26 months (January 2015 to February 2017) evaluating the impact of evidence-based interventions on the incidence of MDR-GNB infections. The study was divided into three phases: Phase-1 (pre-intervention), Phase-2 (intervention), and Phase-3 (post-intervention).Data collectionA. baumannii, K. pneumoniae, P. aeruginosa, and E. coli. The bacterial isolates were collected prospectively from routine clinical samples taken from patients presenting with bloodstream, respiratory tract, skin, soft tissues, and urinary tract infections. Only isolates with healthcare-associated infection were included in the study using the standard definition of infection occurring 48 hours after admission. Each organism was included in the study only once, at the time of the first positive result. The definition of the MDR by the experts from the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) was used for this study, where MDR was defined as the organism to be non-susceptible to at least one antibiotic agent in three or more classes of antibiotics [In Phase-1 (January 2015-June 2016), the data on all isolates of each of the four MDR-GNB were collected prospectively. The organisms included ibiotics . IsolateIn Phase-2 (July-October 2016), targeted interventions were implemented in adult ICUs. The period for the development and implementation of interventions was four months. The interventions included daily bathing of all patients with chlorhexidine solution, cleaning and disinfection of patient’s surrounding twice a day at each change of nursing shift, education of healthcare workers on hand hygiene (HH) compliance, and terminal cleaning and disinfection of rooms occupied by MDR-GNB patients with hydrogen peroxide solution using the fogging technique. An antibiotic restriction form to reduce and control the consumption of restricted antibiotics, especially carbapenems, was simultaneously implemented as part of the hospital antimicrobial stewardship program. The data collection on bacterial isolates continued in Phase-2 also. The data collection continued in Phase-3 (November 2016-Februry 2017) to evaluate the effectiveness of the interventions by comparing the incidence rate of MDR-GNB before and after the intervention. The interventions started in phase two and continued throughout phases two and three. HH observation was also carried out again in phase three to determine the improvement in HH compliance as a result of staff education.Data sourcesThe data for all phases were collected using multiple data sources including• Microbiology laboratory records on Gram-negative bacteria and their sensitivity profiles. This information was available electronically using the hospital information system. • Patients' admission information sent to the infection control office by Information Services Department (ISD) daily was used for calculating hospital patient days that served as the denominator for determining the incidence rate of hospital-acquired infections.• Patients' charts, as well as the electronic patients' record, were used to collect demographic and clinical information and identify risk factors, i.e. antibiotic therapy and use of invasive devices or procedures. Patients' non-electronic charts were also reviewed for any missing information in the electronic records because the electronic system was recently implemented in our institution.HH observationHH observational audits were conducted in the clinical units/wards to determine HH compliance by healthcare workers. Direct HH monitoring was carried out using HH methodology and monitoring tools developed by the World Health Organization (WHO) . The infEnterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR)In Phase-1, genomic DNA extraction was carried out for 148 samples using the Thermo Scientific® GeneJet Genomic DNA purification kit , following the manufacturer’s instructions. Isolates underwent genomic fingerprinting using ERIC-PCR to establish the clonality and the link of different strains within and between the hospital wards/units. The primers for the ERIC-PCR included ERIC 1 5’-ATG TAA GCT CCT GGG GAT TCA C-3’ and ERIC2 5’-AAG TAA GTG ACT GGG GTG AGC G-3’ .For ERIC-PCR, the total reaction size was 10 µL, which contained 2 µL of template DNA, 0.1 µL of each primer (100 μM), 2.8 µl nuclease-free water, and 5 µL of DreamTaq Green Polymerase Master Mix 2× (Thermo Fisher Scientific). PCR reactions were conducted in an Applied Biosystems 2720 programmable thermal cycler  with the following PCR conditions: an initial denaturation step of 94 °C for 3 min, 30 cycles of 30 s of denaturation at 94 °C, 1 min of annealing at 50 °C, 8 min of extension at 65 °C, and a final elongation step of 16 min at 65 °C, followed by storage at 4 °C.ERIC-PCR products were loaded into 1% (w/vol) agarose gels, together with Quick Load® 1-kb DNA ladder  and subjected to electrophoresis at 100V for 2 h. Gels were stained in a solution containing 0.1 mg/ml ethidium bromide for 15 min. Amplification products were visualized by UV trans-illumination, and images were captured using a gel documentation system  and recorded for further analyses.ERIC profiles were analyzed using Bionumerics software . All DNA fragment sizes within each gel were normalized using the Quick Load® 1-kb DNA molecular weight marker as the external reference standard. The similarity between each strain was determined from the homology matrix using the Dice coefficient. Dendrograms were constructed based on the averaged similarity of the matrix using the Jacquard coefficient and the Unweighted Pair-Group Method (UPGMA) algorithm with optimization and band tolerance set a 1% . The co-phenetic correlation value was calculated for the dendrogram to measure generated clusters' reliability. Clusters were defined based on a similarity cut-off of 80%.A. Baumannii isolates was also carried out in Phase-3 to evaluate whether the remaining strains were similar to those in Phase 1 and the variation, if any, after interventions. ERIC-PCR genomic fingerprinting for MDRA. Data analysisThe data were analyzed using IBM SPSS Statistics for Windows, Version 20 . One-way analysis of variance (ANOVA) was carried out to determine the difference between different phases of the study. The level of significance was determined at p-value < 0.05.MDR-GNB incidence A total of 1090 MDR-GNB isolates were collected throughout the hospital over 26 months. The number of isolates collected from the adult ICU was 456 (42%), and the incidence rate was much higher in the adult ICU (22.8/1000 patient-days) compared to the rest of the hospital combined areas (2.3/1000 patient-days). The rate of MDR-GNB was higher in adult ICUs throughout the study period, as shown in Figure The mean incidence of MDR-GNB in the adult ICU in Phases 1, 2, and 3 was 11.08, 6.07, and 3.54 per 1000 patient days. The results show significant differences among the three phases regarding the incidence in adult ICU as indicated by the p-value of the F test (p=0.0005). The mean incidence of MDR-GNB inwards/units other than adult ICU (without interventions) in Phases 1, 2, and 3 was 0.97, 0.85, and 0.72 per 1000 patient days, as shown in Table The results show insignificant differences among the three phases, as indicated by the p-value (p=0. 314). A. baumannii in Phases 1, 2, and 3 in the adult ICU was 12.67, 7.21, and 2.81, respectively. There was an overall reduction of 78%, and the results were found to be statistically significant (p = 0.0001). Likewise, the mean incidence of E. coli in Phases 1, 2, and 3 was 1.33, 0.29, and 0.00, respectively (p = 0.030). The mean incidence of E. coli in areas other than adult ICU was also reduced post-intervention (p = 0.007). The number of E. coli was low in all phases, so the reduction may have been coincidental, as no interventions were implemented in those areas. The mean incidence of K. pneumoniae in Phases 1, 2, and 3 was 9.46, 4.49, and 3.51, respectively. There was an overall reduction of 62%, and the results were statistically significant (p = 0.0001). Similarly, the mean incidence of P. aeruginosa in Phases 1, 2, and 3 was 4.40, 3.17, and 2.53, respectively. Despite some reduction in the rate, the results were not statistically significant (p = 0.115). For individual MDR-GNB, the mean incidence per 1000 patient days ofHH complianceHH compliance was monitored in six clinical areas in Phase-1. The HH compliance in all six areas was 87%, 90%, 92%, 75%, 95%, and 89% in the medicine, surgery, oncology, adult ICUs, pediatric and neonatal ICUs, and hemodialysis units, respectively. The lowest compliance was observed in the adult ICU with only 75%. The HH compliance in the post-intervention phase increased to 88%, which is statistically significant. In Phase-3, HH has only been monitored in adult ICUs. The interventions, including HH education, were implemented in the adult ICU. That is the reason post-intervention monitoring was done only in adult ICUs.ERIC-PCR DNA genomic fingerprintingA. baumannii (n = 55), K. pneumoniae (n = 48), P. aeruginosa (n = 26), and E. coli (n = 19). Fingerprints were examined for differences and similarities in the number and sizes of PCR amplicons. ERIC-PCR results of A. baumannii pre- and post-intervention are presented as an illustrative example.A total of 148 isolates were tested in Phase-1. The isolates included A. baumannii isolates, the majority of which had very similar banding patterns  and four smaller clusters were observed with the s Figure , suggestIsolates within all three major clusters demonstrated similarity with four primary bands and differed with respect to fainter secondary and tertiary amplicons. The majority of the isolates showing a high degree of banding similarity were from the adult ICU indicating the possible transmission of bacteria within the unit and then transfer to patient wards following departure from ICU. Isolates within clusters D-F demonstrated less similarity to the three major clusters, with some of these non-clonal isolates from the adult ICU being transferred to other wards. Cluster G isolates did not appear to originate in the adult ICU. K. pneumoniae isolates, which demonstrated varied ERIC-PCR fingerprints  compared to isolates from other sources and could have been transferred to male and female medical wardss Figure .It is interesting to note that sample 138 from the adult ICU shares a high degree of similarity (70 - 80%) to two isolation ward samples 85 and 38. Similarly, isolate 80 from the CCU and isolate 16 from the isolation ward also shared a high degree of similarity. A third group of interest is the similarity observed for strains 172, 146, and 107, which shared a high degree of similarity and were found in general pediatric, pediatric oncology, and adult hematology wards, respectively.A. baumannii isolates were tested in Phase-3. More clonality was observed with the isolates, as was found in Phase-1. Four clusters were observed .A study conducted by Cheon et al. (2016) in a South Korean hospital investigated the effectiveness of antimicrobial stewardship and comprehensive intensified infection control measures for controlling endemic MDR  in ICUs . The meaventions . Our stuKlebsiella pneumoniae carbapenemase (KPC) producing K. pneumoniae was endemic in their ICU. Therefore, ICU was targeted for an enhanced infection control program. Multiple infection control measures were implemented, including all patients coming to their ICU with a culture positive for ceftazidime- or carbapenem-resistant gram-negative bacillus were positioned in contact isolation also, rectal swab samples were obtained from patients on admission to the ICU and weekly thereafter by means of culture swab. Additionally, improved decontamination of hands and environmental surfaces was applied in the ICU. The results post-interventions were comparable to our study in that they achieved a 62% reduction showing that intervention effectively decreased the incidence of K. pneumoniae in the ICU [A similar study by Kochar et al. (2009) in one of the hospitals in New York also highlighted the importance of interventions. From 2004 to 2005,  the ICU . P. aeruginosa indicated that it was less likely that the bacteria were being transmitted between patients due to the lack of infection prevention practices. These results suggest that a more effective antibiotic stewardship program and strict infection prevention measures are required to achieve the desired reduction in these particular bacteria. The results of a study conducted by Liu et al. (2018) in a Chinese hospital demonstrated that incidence rates of P. aeruginosa at a tertiary hospital decreased from 4.9 to 1.0 per 1000 patient days after implementing infection control interventions combined with an antibiotic stewardship program. The measures included environmental cleaning and disinfection, HH improvement, and education about infection control, together with antibiotic restriction through a classification management system for antibiotic use [The diversity observed for otic use . Compliance rates for HH in our study appear to be much higher than those observed in sub-Saharan Africa, with rates below 25% . They arA. baumannii, and P. aeruginosa in healthcare facilities, especially active screening of colonized patients because the active screen of colonized patients for MDR-GNB was not available in our institution [The interventions selected in our study did not include some of the interventions contained in recently published WHO guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, titution . Most oftitution ,22. The The IPC and stewardship interventions significantly reduced the incidence of common MDR-GNB in adult ICUs, albeit to ascertain the relative contributions of each. Such interventions must be conducted regularly to keep the incidence of MDR-GNB in check. Constant surveillance, proper antibiotics use, and implementation of adequate IPC measures are recommended to reduce the risk of MDR GNB infections.


Objectives: To investigate the dosimetric advantages of the voluntary deep inspiration breath-hold technique assisted by optical surface monitoring system for whole breast irradiation in left breast cancer after breast-conserving surgery and verify the reproducibility and acceptability of this technique. Methods: Twenty patients with left breast cancer receiving whole breast irradiation after breast-conserving surgery were enrolled in this prospective phase II study. Computed tomography simulation was performed during both free breathing and voluntary deep inspiration breath-hold for all patients. Whole breast irradiation plans were designed, and the volumes and doses of the heart, left anterior descending coronary artery, and lung were compared between free breathing and voluntary deep inspiration breath-hold. Cone beam computed tomography was performed for the first 3 treatments, then weekly during voluntary deep inspiration breath-hold treatment to evaluate the accuracy of the optical surface monitoring system technique. The acceptance of this technique was evaluated with in-house questionnaires completed by patients and radiotherapists. Results: The median age was 45 (27-63) years. All patients received hypofractionated whole breast irradiation using intensity-modulated radiation therapy up to a total dose of 43.5 Gy/2.9 Gy/15f. Seventeen of the 20 patients received concomitant tumor bed boost to a total dose of 49.5 Gy/3.3 Gy/15f. Voluntary deep inspiration breath-hold showed a significant decrease in the heart mean dose  and left anterior descending coronary artery . The median delivery time of radiotherapy was 4 (1.5-11) min. The median deep breathing cycles were 4 (2-9) times. The average score for acceptance of voluntary deep inspiration breath-hold by patients and radiotherapists was 8.7 ± 0.9 (out of 12) and 10.6 ± 3.2 (out of 15), respectively, indicating good acceptance by both. Conclusions: The voluntary deep inspiration breath-hold technique for whole breast irradiation after breast-conserving surgery in patients with left breast cancer significantly reduces the cardiopulmonary dose. Optical surface monitoring system–assisted voluntary deep inspiration breath-hold is reproducible and feasible and showed good acceptance by both patients and radiotherapists. However, RT potentially increases the risk of cardiac toxicity owing to heart exposure, especially for left-sided breast cancer.3 The 15-year incidence of cardiovascular events in patients with left breast cancer treated with RT after BCS was 7.6%, compared with 1.1% for those without RT. The heart exposure dose was found to be an important predictor for cardiovascular events. Darby et al reported that the relative risk of major coronary events increased by 7.4% if the mean heart dose increased by 1 Gy.Breast-conserving surgery (BCS) combined with radiotherapy (RT) has become the standard treatment for early breast cancer. Radiotherapy can significantly improve the local control rate and survival rate while conserving the breast. A 3.5-week schedule of hypofractionated RT is noninferior to a standard 6-week schedule of conventional fractionated RT in China, according to Wang 610 However, repeated DIBHs bring intra- and interfraction uncertainties. For example, different breathing maneuvers  can lead to variations in breast position despite the same inspiration volume. To guarantee a reproducible position of both external target breast and internal organ-at-risk heart, image-guided RT during treatment is necessary. Cone beam computed tomography (CBCT) is frequently used to verify the setup accuracy and the level of deep inspiration but at the cost of additional patient exposure to non-therapeutic radiation dose. Optical surface tracking, a nonionizing indirect approach for real-time respiratory motion monitoring, has a stability and localization accuracy within 0.2 mm by tracking an infrared marker affixed over the patient's xiphoid process during DIBH. Optical surface monitoring system (OSMS) (VisionRT) projects visible light on the patient and detects the surface and surface movement caused by respiration. This movement detection can be used to verify the 3-dimensional breast surface position to gate the beam during treatment.1214 Theoretically, it is a useful tool for the surveillance of DIBH treatment in breast cancer. Alderliesten et al reported good agreement in translational setup errors between CBCT and AlignRT based on a region of interest (ROI) incorporating the left-sided breast surface.Compared to free-breathing (FB), deep-inspiration breath hold (DIBH) technique, by expanding the lung and increasing the distance between the heart and the chest wall, can effectively reduce the heart dose.Therefore, we conducted a prospective phase II study to evaluate the efficacy of voluntary deep inspiration breath-hold (VDIBH) on cardiopulmonary sparing and explored the feasibility of real-time image-guided RT by daily OSMS combined with less frequent CBCT. Between January 2017 and August 2017, we screened 25 patients and ultimately ruled out 5 patients, 3 patients who were unable to hold their breath for 35 s, 2 patients who were unable to cooperate with radiotherapists instructions. Finally, 20 consecutive women who met the following criteria were included: age between 18 and 70 years, confirmed left-sided breast cancer, the intention to receive whole breast irradiation  after BCS, proficiency in DIBH, ability to hold breath for at least 35 s and repeat for at least 6 cycles. We have de-identified patient details such that the identity of any person may not be ascertained in any way.This study  was investigator-initiated and designed as a prospective phase II trial. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.All patients underwent CT simulation in a supine position immobilized on the breast bracket . Before simulation, preparatory DIBH coaching and training were performed with computer-controlled, visual feedback active breathing control (ABC) system (Elekta), and the threshold of inspiration volume was identified individually at a comfortable level, typically 70% to 90% of the maximum inspiration volume. Two sets of simulation CT scans, an FB CT scan, and an ABC assisted-DIBH CT scan using the identified threshold of inspiration volume from training were acquired using the same isocenter for each patient .Treatment plans were created on DIBH CTs. The FB and DIBH CTs are fused based on the left breast. The doses of the heart, left anterior descending coronary artery (LADCA), and left lung in FB and DIBH were evaluated according to the DIBH treatment plans for dosimetric comparison. Tangential-based field-in-field simplified intensity-modulated RT was used for these patients. The prescribed dose is 43.5 Gy in 15 daily fractions to the whole breast and 49.5 Gy in 15 daily fractions to the tumor bed if indicated. The DIBH technique was used for all treatments.The DICOM data of the planning CT with skin contour and the isocenter coordinate were sent to the AlignRT workstation. A ROI of the external skin of the treatment area (unstable regions such as axillar were avoided) was selected to serve as the setup reference image. The tolerances were determined for real-time deltas of the on-treatment breath-hold ROI surface to the planned surface as 6-dimensional translation and rotation errors of 3 mm and 3°.At the treatment machine, patients are set up under OSMS. The AlignRT system automatically acquires the ROI of the patient surface and registers it to the reference to calculate real-time deltas. The set-up is considered acceptable if the real-time deltas of the current breath-hold ROI surface to the planned surface are within predetermined tolerances. Cone beam computed tomography is performed to verify the internal target matches. During treatment, the patient is instructed to take a deep breath and hold it, and the radiation beam is turned on automatically while the patient is holding their breath and real-time deltas within predetermined tolerances . Cone beam computed tomography is performed at least for the first 3 fractions, then once a week.All CBCT images were analyzed to assess whether the heart was displaced away from the chest in a manner consistent with the DIBH-planned images. The CBCT images were uploaded to the planning system and registered with the planning CTs based on the breast target. The heart during treatment was contoured on the CBCT . The hea18 The data were statistically analyzed using SPSS version 25.0 (IBM Corporation), and measurement data were compared using the Student t test  or the Wilcoxon rank sum test , which is a nonparametric test. The test level was α = .05. Informed consent was obtained from all individual participants included in the study.A predesigned questionnaire was completed by patients and involved radiotherapists to assess the acceptance of this technique. The translational set up errors were calculated by comparing CBCT with planning CT, and the planning target volume margins were calculated using the following formula: 2.5Σ + 0.7δ, wherein Σ and δ represent the standard deviations of the systematic and random errors, respectively.Twenty patients with left-sided breast cancer were included in this study. The median age was 45 years (27-63 years old). Three (15%), 10 (50%), and 6 (30%) patients had stage 0, I, and II disease, respectively. Seventeen patients (85%) received tumor bed boost and 3 (15%) patients did not. All patients completed the planned treatment without interruption.The heart Dmean, LADCA, the total volume, and V20 of the left lung on FB and VDIBH are shown in mean reduction by VDIBH varied from 19.2% to 74.3%, with a median of 55.3%.mean of CBCT/DIBH-planned varied from 96.9% to 172.4%, with a median of 105% (mean of patients under VDIBH both in CBCT and DIBH-planned was significantly lower than that under FB (P < .005) , indicating high consistency of heart position between simulation positioning and actual RT implementation. The ratio of heart D of 105% .The hear < .005) .The median treatment time of a single fraction was 4 (1.5-11) min. The median number of breath hold repetition per single treatment was 4 (2-9) times. The questionnaires were completed by all 20 patients with a median age of 45 years (range: 27-63) and 9 therapists with a median age of 37 years (range: 25-57) and median working years of 12 (range: 1-38). The average score for the acceptance of VDIBH by patients and therapists were 8.7 ± 0.9 (out of 12) and 10.6 ± 3.2 (out of 15), respectively, indicating good acceptance of the technique by both patients and therapists .The median translational set up errors in X , Y , and Z  directions were 0.01 ± 0.14 cm, 0.02 ± 0.20 cm, and 0.06 ± 0.20 cm, respectively. The corresponding PTV margins were calculated as 0.49 cm, 0.69 cm, and 0.65 cm, respectively.mean was reduced by 55.3% and V20 of the left lung was significantly decreased, which is consistent with previous studies on DIBH (including ABC-DIBH and other DIBH).81822This study suggests that the cardiac radiation dose of left-sided breast cancer was significantly reduced by the use of VDIBH. The position of the heart was reproducible during treatment. The median treatment time of 4 min and feedback from patients and therapists indicated that RT using VDIBH and OSMS was acceptable. The PTV margins under VDIBH were <1 cm. In the present study, the heart D21 In this study, we found high consistency of heart position and heart dose between daily CBCT and the planning CT.Previous studies on the effects of DIBH on cardiac radiation dose focused on the dosimetric analysis in treatment planning, which did not reflect the actual heart position and dose in daily treatment.Traditional ABC-DIBH devices have been widely used, and their physical benefits have been recognized by many studies. However, the process is complex, and many patients have difficulty accepting it. With the development and widespread use of the OSMS technology, the simpler VDIBH technology can be realized. We verified the accuracy and physical benefits of OSMS-assisted VDIBH. This is, to the best of our knowledge, the first study about the acceptance of OSMS-assisted VDIBH treatment by patients and therapists. A predesigned questionnaire was completed by patients and involved therapists to assess the acceptance of this technique. During the initial positioning, we let all patients experience ABC-DIBH training. With a full score of 15 points, 8 of 9 therapists scored more than 10 points, indicating good acceptance of VDIBH. But the oldest therapist (57 years) gave the lowest total score (3 points). No correlation between scores and age was found after statistical analysis. We also designed a question (No 4: How do you feel about VDIBH gating RT compared with utilization of ABC devices?) to compare the experience of ABC and VDIBH workflow. All patients gave 2 or 3 points, which means that VDIBH is more comfortable than ABC-DIBH.In this study, the proposed PTV margins of 0.49 cm, 0.69 cm, and 0.65 cm in the lateral (L/R), cephalo-caudal (C/C), and ventral-dorsal (V/D) directions, respectively, were comparable with those under DIBH reported in literature . Wang et al reported that the reduction of cardiac dose radiation is an independent prognostic factor for the incidence of subclinical cardiac events. Further research may prove that a reduction in cardiac radiation dose will result in a significant survival benefit for patients with breast cancer.In this study, VDIBH was thoroughly evaluated with respect to RT planning and technical implementation. The feasibility and physical advantages of the proposed therapy were clarified.et al demonstrated that the accuracy of the reference images reconstructed based on the outer contour was lower than that of the optical images directly collected at the CT simulation end. Second, the feasibility of VDIBH's physical advantages being transformed into long-term clinical cardiac benefits  requires further long-term follow-up.This study has limitations. First, in terms of OSMS reference images, no infrared camera was arranged at the CT simulation end, and the reference images of the surface could only be reconstructed based on the outer contour of the positioned CT images. Gierga Compared with FB, OSMS-assisted VDIBH for WBI can significantly reduce the cardiopulmonary radiation dose of patients with left-sided breast cancer. The heart position and dose in actual treatment were highly consistent with those in the planning system. Both patients and therapists exhibited good acceptance of the proposed therapy.Click here for additional data file.Supplemental material, sj-docx-1-tct-10.1177_15330338231173773 for Voluntary Deep Inspiration Breath-Hold (VDIBH) Whole-Breast Irradiation Assisted by Optical Surface Monitoring System (OSMS) in Patients With Left-Sided Breast Cancer: A Prospective Phase II Study by Jiang-Hu Zhang, Tan-Tan Li, Shi-Rui Qin, Zhi-Qiang Liu, Si-Ye Chen, Yong-Wen Song, Yu Tang, Hao Jing, Hui Fang, Xu-Ran Zhao, Jing Jin, Yue-Ping Liu, Yuan Tang, Shu-Nan Qi, Ning Li, Bo Chen, Ning-Ning Lu, Ye-Xiong Li and Shu-Lian Wang in Technology in Cancer Research & Treatment


Clonal hematopoiesis of indeterminate potential (CHIP) is associated with atherosclerosis and cardiovascular disease. It has been suggested that CHIP may be related to diabetes, so we investigated the association between CHIP and new-onset type 2 diabetes.This study included 4,047 subjects aged >=40 years without diabetes. To detect CHIP, targeted gene sequencing of genomic DNA from peripheral blood cells was performed. The incidence of new-onset type 2 diabetes during the follow-up period was evaluated.p = 0.039). In a univariate analysis, CHIP significantly increased the risk of new-onset diabetes , but in a multivariate analysis, it was not significant. The CHIP-related risk of new onset diabetes differed according to LDL cholesterol level. In the hyper-LDL cholesterolemia group, CHIP significantly increased the risk of diabetes , but it did not increase the risk in the non-hyper-LDL cholesterolemia group. The subjects with CHIP and hyper-LDL-cholesterolemia had approximately twice the risk of diabetes than subjects without CHIP and with low LDL cholesterol .Of the total subjects, 635 (15.7%) had CHIP. During the median follow-up of 5.1 years, the incidence of new-onset diabetes was significantly higher in CHIP carriers than in subjects without CHIP (11.8% vs. 9.1%, The presence of CHIP was a significant risk factor for new-onset type 2 diabetes, especially in subjects with high LDL cholesterol. These results show the synergism between CHIP and high LDL cholesterol as a high-risk factor for diabetes. The development of type 2 diabetes is very complex, involving several genetic and environmental factors. Age, race/ethnicity, family history of diabetes, obesity, and physical inactivity are known as traditional risk factors . HoweverAging is accompanied by the accumulation of somatic mutations in hematopoietic stem cells. These mutations can cause hematologic malignancies, such as acute leukemia, but this does not happen in most individuals. The clonal expansion of hematopoietic cells with aging-related recurrent somatic mutations in the absence of other hematologic abnormalities is called clonal hematopoiesis of indeterminate potential (CHIP) . CHIP haType 2 diabetes is a potent risk factor for cardiovascular disease and atherosclerosis. Like CHIP, type 2 diabetes is associated with aging. A meta-analysis reported that type 2 diabetes is associated with an increased risk of hematologic malignancy . These rn = 64) were excluded, and 4,927 subjects were finally analyzed -CHIP cohort was designed to investigate the effects of CHIP on health outcomes. This retrospective cohort included subjects aged ≥65 years or aged 40–64 years with more than one of the risk factors for cardiovascular disease  who came to the Seoul National University Hospital Healthcare System Gangnam Center for a health check-up for screening purposes between January 2014 and January 2017. The GENIE-CHIP cohort was a subcohort of the GENIE cohort, and details of the GENIE cohort were described previously . Of the analyzed . Type 2 Informed consent was obtained from participants in the GENIE cohort, and blood samples were collected with the approval of the Seoul National University Hospital Institutional Review Board (H-1103-127-357). The protocol of this retrospective cohort study was additionally approved by the institutional review board (H-1908-121-1056), and informed consent was waived owing to its retrospective nature.Genomic DNA was isolated from peripheral blood. Targeted gene sequencing was performed using an Agilent SureSelectXT HS custom panel and the Illumina NovaSeq 6000 with 2 × 150 bp paired-end reads with a minimum coverage of 800 ×. The custom panel comprised all the exons of 89 genes frequently involved in CHIP, such as DNMT3A, TET2, ASXL1, JAK2, and TP53 , 16–18. t-test for independent samples or the Mann–Whitney test. Categorical variables are expressed as numbers and percentages and were compared using the χ2 test or Fisher's exact test. The association between the presence of CHIP and new-onset type 2 diabetes was tested using a Cox proportional hazard model with covariates including age, sex, BMI, and other diabetes risk factors. Diabetes-free survival, estimated using the Kaplan–Meier method, was compared between the groups using the log-rank test. The attributable proportion (AP) due to the interaction between CHIP and high LDL cholesterol was calculated using the epiR package of R statistics . For this analysis, participants were included in the hyper-LDL cholesterolemia (hyperLDLC) group if their LDL cholesterol level was ≥160 mg/dL  (Continuous variables are presented as the mean ± standard deviation or median with interquartile range and were compared using Student's Program) , 21 or ip < 0.001) and had lower levels of LDL cholesterol . However, sex, BMI, waist circumference, and the prevalence of hypertension and dyslipidemia were not different between subjects with and without CHIP  had CHIP . The preout CHIP . Of the p = 0.039). The Kaplan–Meier curve demonstrated that CHIP carriers had a higher risk of new-onset type 2 diabetes . However, in a multivariate analysis adjusting for age, sex, BMI, and family history of diabetes, it was not significant   had at least one follow-up examination. The baseline blood levels of glucose and HbA1C were slightly higher in subjects with CHIP than in subjects without CHIP . The med= 0.194) .In addition, it was investigated whether CHIP clone size or specific CHIP mutation contributed more to the increased risk of new-onset type 2 diabetes. Among CHIP carriers, 14.4% (92/635) had large CHIP clones defined as VAF ≥10%. Large CHIP carriers had a higher risk of new-onset type 2 diabetes compared with small CHIP carriers or subjects without CHIP in the Kaplan–Meier curve . When exp = 0.030, p = 0.004; p = 0.018) but not in the non-hyperLDLC group  (p < 0.001). This interaction between LDL cholesterol and CHIP may significantly contribute to the development of new-onset type 2 diabetes, at a rate of 34%  . Further= 0.894) . The sube of 34% . It sugge of 34% .The present study demonstrated that CHIP increased the risk of new-onset type 2 diabetes in subjects with high LDL cholesterol. CHIP had a significant interaction with LDL cholesterol, and they showed synergism in increasing the risk for new-onset type 2 diabetes. The risk for new-onset type 2 diabetes in CHIP carriers in the hyperLDLC group was twice that of non-CHIP carriers in the non-hyperLDLC group.p = 0.069), and this may be because of the small number of large CHIP carriers. Further large-scale longitudinal studies on the association between CHIP and new-onset type 2 diabetes are needed to validate our results.To the best of our knowledge, this is the first cohort study demonstrating a significant association between CHIP and the development of new-onset type 2 diabetes. Although Jaiswal et al. reported the association between CHIP and type 2 diabetes for the first time, it was a cross-sectional study . AdditioAmong genes mutated in CHIP, DNMT3A and TET2 were the most frequent , 14, 23.CHIP may affect insulin resistance and contribute to the development of type 2 diabetes. Fuster et al. generated mice with CHIP to investigate the effect of CHIP on atherosclerosis and insulin resistance , 25. TetCHIP shifts macrophages to a more inflammatory state. Dnmt3a or Tet2-deficient J774.1 myeloid cells created using a lentivirus/CRISPR system showed increased expression of inflammatory cytokines and chemokines, such as IL-1β, IL-6, and CCL5 . Inflamm−/−) or LDL receptor-deficient (Ldlr−/−) mice fed high-fat diets showed proliferation of hematopoietic stem cells as well as leukocytosis in peripheral blood  but not in the non-hyperLDLC group (adjusted HR 0.98). The hyperLDLC group included 45% 540/1203) statin users. Statin use can increase the risk of diabetes, and a meta-analysis reported an odds ratio of 1.09 for new-onset type 2 diabetes , 30. Eveal blood –40. Thes/1203 staThis study has some limitations. Since our study did not evaluate inflammatory markers/cytokines, such as IL-6, oxidized LDL, small dense LDL, or insulin resistance, it was difficult to elucidate the mechanism by which CHIP interacts with LDL cholesterol to increase the risk of type 2 diabetes. Further studies are needed to determine the underlying mechanism of the association between CHIP and type 2 diabetes. The time and number of follow-up examinations were different for each subject due to the nature of this retrospective cohort study.This is the first study to demonstrate that the presence of CHIP was significantly associated with the development of type 2 diabetes. In particular, CHIP and high LDL cholesterol levels synergistically increased the risk of new-onset type 2 diabetes. CHIP may be a hidden risk factor for type 2 diabetes.shany00@gmail.com).The datasets presented in this article are not readily available because of patent issues. Requests to access the datasets should be directed to HS (The studies involving human participants were reviewed and approved by Seoul National University Hospital Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.YK and S-YC designed the study. MK, HS, YK, HL, HP, JY, and S-YC collected, analyzed, and interpreted the data. MK and HS wrote the manuscript. YK, HL, HP, SC, JY, and S-YC contributed to the discussion and reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.


In conclusion, B-OTSC was a safe, secure, and cost-effective method of closure after duodenal ESD, even in patients with post-ESD defects of more than half the circumference.Duodenal endoscopic submucosal dissection (ESD) is associated with high incidences of intraoperative complications and delayed adverse events (AEs). Delayed AEs can be reduced by closing the post-ESD defects. We developed a new method of closure after duodenal ESD, combining endoscopic ligation with O-ring closure (E-LOC) with an over-the-scope clip (OTSC) . Here, we conducted a single-center, retrospective, observational study to investigate the efficacy and safety of the B-OTSC method for preventing delayed AEs in patients undergoing duodenal ESD. The study included nine patients with superficial nonpapillary duodenal epithelial tumors who underwent ESD and were closed with B-OTSC from February 2021 to February 2023. There were no delayed AEs (0%), the mean (± standard deviation) closure time was 53 ± 21.6 min, the complete closure rate was 100%, and the mean hospital stay was 7.8 ± 1.8 days. The sustained closure rates at postoperative days 3 and 7 were 88.9% and 88.9%, respectively. The historical analysis indicated a significant difference in cost between B-OTSC and conventional OTSC ( The detection rate of duodenal tumors has recently been increasing due to improved observational awareness and developments in endoscopic modalities . The crup < 0.001)  [n (C-OTSC) = 1–11]The secondary outcomes included the complete closure rate, the defect closure time, sustained closure rates at POD3 and POD7, AEs related to B-OTSC, and the duration of hospitalization. Complete defect closure was defined as a successful closure covering >90% of the maximum wound length. The defect closure procedure time was defined as the duration between placement of the first and final hemoclips deployed on the defect. Sustained, partial, and unsustained closures were defined as maintenance of the wound length at >80%, 50% to <80%, and <50%, respectively. In an additional analysis, we compared the clinical efficacy and total costs of closure by B-OTSC with conventional OTSC (C-OTSC) using historical data in our hospital. The C-OTSC group compromised 11 consecutive patients who underwent duodenal ESD from January 2012 to July 2019, using TGs rather than E-LOC. We used TGs in all cases of C-OTSC. The shorter axis (Sn) cm2/min = An/DTn [n (B-OTSC) = 1–9] [n (C-OTSC) = 1–11]The dissected area per minute during ESD . p < 0.05 was considered statistically significant. All statistical analyses were conducted using JMP 15.1.0 .The proportions and characteristics of the outcomes were presented as simple descriptive statistics. The categorical variables were expressed as absolute and relative frequencies. The differences between categorical variables were examined by Fisher’s exact test when required, and the continuous variables were compared using Mann–Whitney U test. The patient and lesion characteristics and ESD outcomes are shown in p < 0.01).In an additional analysis, we compared B-OTSC with conventional C-OTSC using historical data . The meaIn this retrospective study, we treated nine patients with B-OTSC for the closure of post-ESD defects. Complete closure was achieved in all cases, with no postoperative AEs. The mean resection diameter was 34.1 ± 6.4 mm, and the study population included three patients with post-ESD defects over half the circumference. In addition, B-OTSC was significantly cheaper than C-OTSC. We identified three important findings regarding the B-OTSC method. First, we achieved complete and endurable closure of the post-ESD defects, even in cases where the lesion involved more than half the circumference. Second, B-OTSC was easier than C-OTSC because OTSCs could be placed with simple suction after shortening the post-ESD defects with E-LOC. Finally, B-OTSC offers a cost benefit compared to C-OTSC as it does not require TGs and reduces the number of OTSCs required.Regarding AEs after duodenal ESD, DP and DB were previously reported to be less common in patients with defect closures compared to those without closure ,22,23, ap < 0.01). The incidence of complete closures was also significantly lower for lesions > 40 mm in size compared with smaller lesions . There was also a significant difference in the incidence of complete closures between lesions occupying ≤49% and ≥50% of the circumference  [Mizutani et al. retrospectively analyzed the results of 698 duodenal endoscopic resection lesions and showed that a medial/anterior wall lesion location and a large lesion size were independent predictors of failure to close the mucosal defect, with a significantly lower incidence of complete closure for lesions located in the medial/anterior wall compared with the lateral/posterior wall  . Thus, tA high rate of complete closure of 90–98% has been reported for OTSC, compared with 67% for clip closure ,27,28. Ip = 0.019), with significant differences in the occurrence of persistent bleeding between the groups (p = 0.027). All cases of bleeding were managed successfully by rescue therapy with OTSCs [p = 0.001). Further bleeding occurred in 57.6% of the cases in the ST group and 15.2% in the OTSC group (absolute p = 0.001) [p = 0.017) [Various studies have compared OTSC versus standard therapy (ST) for the treatment of nonvariceal upper gastrointestinal bleeding. A randomized controlled trial found a clinical success rate of 91.7% in the OTSC group compared with 73.1% in the ST group (th OTSCs . Schmidt= 0.001) . In a su= 0.017) . These r= 0.017) . In addiIn terms of the medical costs, C-OTSC and B-OTSC using OTSCs are more expensive than ST. However, the duodenal muscle layer is thin and there is a risk of perforation with hemostatic coagulation in cases of rebleeding, whereas hemoclips may be difficult to use in patients with chronic ulcers with fibrosis, and surgical salvage therapy after technical failure has been reported . TherefoThe B-OTSC method has the advantage of simplicity. The post-ESD defect is shortened by E-LOC, and OTSC closure can be performed by a simple suction method without the use of a TG. Three defects were ≥50% of the circumference (33.3%), but all the defects (100%) were closed successfully. In addition, B-OTSC prevents the accidental suction of other organs outside the wall, which is considered a complication of OTSC. Only the duodenal wall can be closed by deploying an OTSC just on the E-LOC for lesions that are less than half the circumference. Furthermore, when an OTSC is applied to the slit-shaped defect area on either side of an E-LOC, the mucosa is in close proximity and is mainly closed in lesions that are greater than half the circumference. This technique is particularly useful for preventing injury of the pancreas for defects on the descending papillary side. However, B-OTSC should not be performed within 1 cm of the papilla of Vater in order to reduce the risk of pancreatitis. The closure line should be placed along the short axis direction due to the narrow lumen of the duodenum and the high risk of stenosis. Therefore, we excluded lesions with a longitudinal diameter > 40 mm in the axial direction of the intestine because it was difficult to close these with OTSCs in the short axis direction. These defects were also too long in the longitudinal direction to be closed by OTSCs and E-LOC. Thus, defects > 40 mm should be closed using the string clip method or poly-glycolic acid (PGA) sheets ; howeverOne disadvantage of OTSC is that it is six to seven times more expensive than clip closure ; howeverOur study also had several limitations. First, it was a single-center, retrospective study with a small sample size. Second, the study did not include duodenal bulb cases and was biased at the site of the lesion. Therefore, further multicenter, prospective studies with larger sample sizes are needed to confirm the current results.The B-OTSC method combining E-LOC and OTSC is a safe, effective, and cost-effective method for closing duodenal post-ESD defects, including those that are more than half the circumference.


Ribes nigrum) contain these phytochemicals with therapeutic benefits. The current study presents a report on a standardized BC gemmotherapy extract (BC-GTE) that is prepared from fresh buds. It provides details about the phytoconstituent profile specific to the extract as well as the associated antioxidant and anti-neuroinflammatory properties. The reported BC-GTE was found to contain approximately 133 phytonutrients, making it unique in its composition. Furthermore, this is the first report to quantify the presence of significant flavonoids such as luteolin, quercetin, apigenin, and kaempferol. Drosophila melanogaster-based tests revealed no cytotoxic but nutritive effects. We also demonstrated that adult male Wistar rats, pretreated with the analyzed BC-GTE and assessed after lipopolysaccharide (LPS) injection, did not show any apparent increase in body size in the microglial cells located in the hippocampal CA1 region, while in control experiments, the activation of microglia was evident. Moreover, no elevated levels of serum-specific TNF-α were observed under the LPS-induced neuroinflammatory condition. The analyzed BC-GTE’s specific flavonoid content, along with the experimental data based on an LPS-induced inflammatory model, suggest that it possesses anti-neuroinflammatory/neuroprotective properties. This indicates that the studied BC-GTE has the potential to be used as a GTE-based complementary therapeutic approach.Many plant-derived flavonoids are known for their anti-neuroinflammatory and anti-neurodegenerative effects. The fruits and leaves of the black currant (BC,  TNF-α  is a pro-inflammatory molecule of the Th1-class and is known to play a crucial role in brain development by affecting the development and function of the hippocampus [TNF-α can indicate the presence of inflammation. The neuroprotective effect of flavonoid-rich foods or drinks has been linked to enhanced neuronal connection and communication, including an ability to suppress neuroinflammation. These effects have the potential to promote memory, learning, and cognitive function in the hippocampus [Ribes nigrum) emerges as a superfood due to its phytonutrient profile and the associated health effects [TNF-α gene expression in LPS (lipopolysaccharide) induced cultured macrophages [TNF-α transcription [TNF-α [In general terms, research on flavonoids involves the isolation, identification, characterization, and understanding of their functions, along with investigating potential health benefits associated with their consumption . Flavonopocampus . Howeverpocampus ,6,7. Gropocampus . The bla effects . Some BCrophages . Other scription . Furthern [TNF-α . The aboDrosophila melanogaster-based in vivo nutritional test system to assess the BC-GTE effect on viability. Furthermore, to investigate the anti-neuroinflammatory properties of our BC-GTE, we conducted an in vivo test using rats (Rattus norvegicus), where lipopolysaccharide was applied to induce inflammation through microglia activation [TNF-α production during LPS-induced inflammation.Therefore, we have proposed to obtain a BC-GTE that is standardized with respect to its flavonoid content and antioxidant activity, as these features would greatly facilitate the reproducibility of experiments. Next, we used a tivation . The factivation , along wTrigonella foenum-graecum) was invoked to explain the associated antidiabetic properties [The BC-GTE was subjected to a HPLC–ESI-MS analysis, which detected the presence of 133 phytonutrients. These phytonutrients were primarily from the flavonoid class of polyphenols, although other chemical compounds such as carboxylic acids, amino acids, vitamins, alkaloids, esters, terpenes, and others were also identified . Our quaoperties . Based ooperties . Furtheroperties . The ideNoticeably, our study indicates that the flavonoids are the most numerous phytonutrients in the BC-GTE since we could identify about 80 of them, comprising both non-glycosidic and glycoside types. The most important non-glycosidic flavonoids are luteolin, quercetin, and apigenin, which together quantitatively represent 91.7% of all flavonoids, whereas the presence of kaempferol looks diminished see . NoteworDrosophila melanogaster-based nutritive test system where embryos of the same age and genotype were put on 0M and NM culture conditions supplemented with the BC-GTE at different concentrations . Therefore, by mixing 0.5 mL, 1 mL, 2 mL, 3 mL, and 4 mL of BC-GTE stock solution with 4 mL of 0M or NM culture media, we were able to assess the BC-GTE-generated effect at concentrations such as 11, 20, 33.3, 42.8, and 50%. The 0M represented a dietary condition that did not provide nutrients to support the larval development of fruit flies, and consequently, the hatched first-instar larvae would die instantly due to the lack of nutrients. Interestingly, when the 0M contained 11% and 20% of BC-GTE, no 2nd instar larvae were observed in the culture vessels, suggesting that the extract was not able to cover the nutritional requirements of the early phase of larval development . Interestingly, the most extensively studied compounds in this group have been found to possess anti-inflammatory properties, such as caffeic acid, which has been shown to be relevant for intestinal inflammation  and metaIt is essential to notice that the multiple anti-inflammatory effects reported in the case of individual flavonoids and carboxylic acids have not been thoroughly reviewed. Nevertheless, the presence and combination of these phytonutrients strongly indicate that the BC-GTE might possess neuroprotective and/or anti-inflammatory properties.Drosophila melanogaster-based tests, as well as the significant flavonoid content and relevant in vitro antioxidant activity, we decided to investigate the anti-inflammatory potential of the BC-GTE. For this purpose, we utilized the rat (Rattus norvegicus)-specific LPS-induced neuroinflammatory model, which is widely accepted in the field of inflammation research . Firstliew, see . Our secell size ,44. Inteammation ,45. It iammation . These pammation ,48.p < 0.001; p < 0.01), an effect that indicates the inflammatory potential of the LPS. Moreover, no significant differences are apparent among all samples regarding the microglia number and the thickening of the proximal processes of microglial cells in all analyzed samples . Analyzing the hippocampal CA1 area of the rats 72 h after LPS injection, we observed a significant reduction in the body size of microglia in the case of BC-GTE pretreatments compared to controls  the “saline” group, where animals were pretreated with the solvent mix of the BC-GTE and the LPS was replaced with the saline injection; (ii) the control animals before LPS injection; and (iii) the animals pretreated with BC-GTE before LPS injection. Our results indicated that the pretreatment with BC-GTE prevented the rise of the circulating TNF-α levels following LPS injection, further suggesting that the BC-GTE would possess a relevant anti-neuroinflammatory effect.As mentioned earlier, luteolin, quercetin, apigenin, and kaempferol, the most important flavonoids identified in BC-GTE when assessed independently, were reported to have immunomodulatory and anti-inflammatory properties. Other studies indicated that the stimulation of the innate immune system through LPS injection could activate microglial cells. Their morphological changes would be accompanied by secreting pro-inflammatory cytokines such as TNF-α , eventuaTNF-α . To furtividuals . MoreoveFresh buds of BC were harvested annually around the February-March period in Cluj, Romania, from an organic crop culture (ECOINSPECT certificate Ro-008) for three consecutive years. Each time the extractions were performed at cold temperatures by periodic mixing of the fresh vegetal material with the solvent (96% vol. ethanol—100% glycerol = 1:1) for 20 days. The extraction ratio was 1:20, while the extracted solutions were separated from the vegetal rests by decantation and pressing at 400 atm. The obtained BC-GTEs could be stored at room temperature for at least 2 years without affecting their total flavonoid content and antioxidant activity.A Dionex Ultimate 3000RS UHPLC (ultra high-performance liquid chromatography) system equipped with a Thermo Accucore C18 column, 100/2.1 with a particle size of 2.6 μm, was coupled to a Thermo Q Exactive Orbitrap mass spectrometer equipped with an electrospray ionization source (ESI), and the measurement accuracy was within 5 ppm.3 as a coloring agent. The flavonoids were determined quantitatively using a Shimadzu Nexera-i HPLC equipped with Fortis C18 columns (150 × 2.1 mm × 3 µm) and a UV–Vis DAD detector at 360 nm. The elution was performed with a solvent gradient  was evaluated by the spectrophotometric method as described in the Romanian Pharmacopoeia (1993) at 430 nm with AlClient see . The staient see . The antDrosophila melanogaster-based nutrition tests were carried out using the wm4h (white mottled 4) mutant strain. These experiments were performed in parallel at 25 °C and by applying two different dietary conditions: [To assess the putative cytotoxicity of BC-GTE, ditions:  zero medEight months old, male Wistar rats were housed in groups  so that a standard laboratory diet and water were provided ad libitum at a 12 h light/dark cycle. The animals were randomly divided into three groups, of which two were the saline group (n = 6), the control group , and the BC-GTE group (n = 6). The saline group and the control group received a diluted stock solution that contained 40% ethanol, 40% vegetable glycerin, and 20% water. The third group (BC-GTE) received a specific drink: a diluted stock solution of BC-GTE having 40% ethanol, 40% vegetable glycerin, and 20% BC bud material extract for 4 weeks. The contents of the drinking vessels were replaced daily with 250 mL of freshly prepared drinks, while the stock solutions were diluted at 1:7500 based on the recommendations of the gemmotherapy literature .All experimental procedures on animals were approved by the Animal Examination Ethics Council of the Animal Protection Advisory Board at Semmelweis University , which fully complied with the principles of EU Directive 2010/63/EU for animal experiments.g for 15 min at 4 °C. Following the supernatant removal, the samples were kept on ice until they were assayed.After a four-week long administration period, there were collected blood samples from the right foot saphenous vein. During the following day, the two groups of animals (Control and BC-GTE) were administered an intraperitoneal injection of LPS  at a dose of 1 mg/kg body weight. This concentration has been used in most inflammation-related animal studies ,53,54. TTNF-α were measured by a commercial TNF-α ELISA kit, and the protocol provided by the vendor was followed . We measured the optical density (OD) in each sample with a microplate reader, and we calculated the mean OD from the triplicates. The OD of the sample was compared to a standard curve according to the manufacturer’s instructions. The inter- and intra-assay precisions were <10% (% coefficient of variation).The concentrations of 2 anesthesia after 72 h of the LPS injection. The obtained brain samples were processed for immunohistochemical evaluation and stained with the IBA-1 antibody as described in [2O2 and incubated with 1:2500 rabbit-anti IBA-1  in 2% BSA and 0.1% TX overnight at 4 °C. On the next day, we continued the protocol with 3 × 10 min PBS washing. We used 1:500 goat anti-rabbit secondary antibody  for two hours at room temperature and avidin–biotin peroxidase complex  for one hour. Sections were DAB-labeled (0.075 mg/mL DAB).We sacrificed the animals by transcardial perfusion with saline containing heparin under COribed in . Briefly2 in the case of the original microscopic section, and from 5 to 10 microglial cells were analyzed in each square. The ramified microglia can transform into an “activated state”, characterized by swollen ramified cells with a larger cell body and shorter, thicker processes, or alternatively, the microglia can adopt a “reactive state”, typically characterized by small, spherical cells. These morphological features of the immunostained microglia were assessed by image analysis software .Two immunohistochemically labeled pictures per rat were obtained from the hippocampal region-specific CA1 area . In each picture, a square was drawn, covering the equivalent of 50.000 µmt-test. All numerical data were represented as mean ± SEM (standard error of the mean). Differences were considered significant for p < 0.05.The Statistica 13.5.0.17 soft was applied to assess the laboratory animal experiments’ specific data. The immunohistochemistry and ELISA (enzyme-linked immunosorbent assay) results were evaluated using a Student’s In this paper, we present the first analysis of a BC-based GTE obtained from fresh buds. We report the extract’s chemical composition and demonstrate its anti-neuroinflammatory/neuroprotective effect. In addition to its significant antioxidant activity, the studied BC-GTE contains about 133 phytoconstituents, of which the flavonoids are the most numerous category, with more than 80 representatives, outnumbering all the other assessed bioactive compound categories. We also show that quantitatively, the BC-GTE flavonoid profile excels in luteolin, quercetin, apigenin, and kaempferol, but the presence of rutin and naringenin is also noticeable. The interference of flavonoids with inflammation and the immune system has gained much attention in the past decade . For theTNF-α protein level [TNF-α due to LPS induction. This means that the TNF-α level could be considered indicative of microglial activation and neuroinflammation [Our study aims to shed light on the possible implication of the BC-GTE in overcoming neuroinflammation because the flavonoids seen in our extract were revealed to generate anti-neuroinflammatory properties . Neuroinin level . It has ammation .TNF-α level. Therefore, our results suggested that the BC-GTE, through its phytoconstituent profile, could overcome the early phase of neuroinflammation, probably by not prolonging the pro-inflammatory status of microglia. It is also possible that other compounds of the BC-GTE, such as tryptophan and kynurenic acid, the flavonoid naringenin [The above-mentioned experimental approach successfully recapitulates neuroinflammation in laboratory conditions. Therefore, it could serve as a valuable tool for defining novel therapeutic strategies to treat/prevent neurodegenerative diseases and/or psycho-affective disorders with inflammatory components . Our repringenin , or carbDrosophila melanogaster tests. The administration of BC-GTE prior to the LPS-induced neuroinflammation appeared to decrease microglia activation in the adult rat brains and the serum-specific TNF-α levels. These latter results are promising but, based more on a pilot study, would require in-depth analyses regarding the elicited anti-neuroinflammatory effect. Though further studies are needed to define the cellular mechanisms behind the generated biological effects, the BC-GTE-based approach holds the promise of complex therapy in the case of damaged brain functions and related diseases.Our research was based on a standardized BC-GTE whose phytonutrient profile was thoroughly analyzed both qualitatively and quantitatively. This approach could provide much-needed consistency and continuity for future studies. In addition to flavonoids, the BC-GTE contained other polyphenols, carboxylic acids, and essential amino acids and featured nutritive properties as revealed by


Brevibacillus thermoruber strain 7, to degrade Ɛ-polycaprolactone (PCL), as well as the enzyme purification, the characterization of its physicochemical properties, the product degradation, and its disruptive effect on the PCL surface. The pure enzyme showed the highest reported optimum temperature at 55 °C and a pH of 7.5, while its half-life at 60 °C was more than five hours. Its substrate specificity referred the enzyme to the subgroup of lipases in the esterase group. A strong inhibitory effect was observed by detergents, inhibitors, and Fe3+ while Ca2+ enhanced its activity. The monomer Ɛ-caprolactone was a main product of the enzyme degradation. Similar elution profiles of the products received after treatment with ultra-concentrate and pure enzyme were observed. The significant changes in PCL appearance comprising the formation of shallower or deeper in-folds were observed after a week of incubation. The valuable enzyme properties of the lipase from Brevibacillus thermoruber strain 7, which caused a comparatively quick degradation of PCL, suggests further possible exploration of the enzyme for effective and environment-friendly degradation of PCL wastes in the area of thermal basins, or in thermophilic remediation processes.The tremendous problem with plastic waste accumulation has determined an interest in biodegradation by effective degraders and their enzymes, such as thermophilic enzymes, which are characterized by high catalytic rates, thermostability, and optimum temperatures close to the melting points of some plastics. In the present work, we report on the ability of a thermophilic lipase, by  Several decades ago, synthetic polymers with long molecules, named plastics, were introduced as substitutes for natural materials and since then they have invasively entered almost every area of industry and social life by making them more colorful, easier, and safer . Despite6H10O2)n (PCL) is produced from crude oil by the ring-opening polymerization of Ɛ-caprolactone and 2-methylene-1-3-dioxepane has attractive polymer characteristics, such as low-temperature flexibility, gloss, UV- and wear resistance, non-hazardous nature, and good biocompatibility, which determines its applicability in implants, surgical drapes, wound dressing, injection-molded devices, drug delivery, etc. (30 kDa)  making t(30 kDa) . Among t(30 kDa) at 70 °C . The enztability . The pos reports . The obs protein ,37. The  protein ,38. The  protein . Signifiand EDTA . InvestiAlcaligenes faecalis was also described as a lipase [B. subtilis enzyme has shown the highest substrate specificity to p-nitrophenyl-acetate [Thermobifida alba expressed in Escherichia coli has degraded aliphatic-aromatic copolyester with a preference for p-nitrophenyl acyl esters (C2 to C8), indicating that the enzyme is an esterase rather than a lipase [Pseudomonas pseudoalcaligenes (PpCutA) and lipase in Pseudomonas pelagia (PpelaLip) [The higher substrate preference of the enzyme synthesized by strain 7 to pNPP than to pNPB clearly demonstrated its affiliation to the subgroup of lipases (EC 3.1.1.3) rather than to the true esterases (EC 3.1.1.1). The partially purified enzyme from a lipase . B. subt-acetate . An este-acetate . Thermoba lipase . The putpelaLip) .Ideonella sakaiensis 201-F6 (IsPETase) has been characterized by high substrate specificity [Streptomyces sp. SM14 was reported to also express some PCL activity [GPC analysis of the degradation products revealed that the enzyme from strain 7 attacked the main chain of PCL by exo-mechanism of action with a monomer as a main product. As the only peak observed in the supernatant after 48 h of strain cultivation was the monomer , the appcificity ; howeveractivity .Bacillus subtilis at 30 °C [Bacillus sp. [Pseudomonas, Alcanivorax, and Tenacibaculum at 25 °C [SEM analysis revealed deep changes in the PCL pearl surface after a week. A similar deeply destroyed PCL surface has been observed during the growth of strain 7 in a medium with PCL as the only carbon source . Visiblellus sp. , a week at 25 °C . HoweverBrevibacillus thermoruber strain 7 in a medium with PCL as the only carbon source. This enzyme represents the first thermostable enzyme active on PCL that was isolated, purified and characterized in relation to its properties, the received hydrolysis products, and plastic surface damages. An effective scheme for lipase purification was suggested that provided a high purification factor and a comparatively good yield. The high-temperature optimum, high thermostability, and large pH area of activity determine the enzyme as very appropriate for remediation processes of PCL wastes at temperatures close to PCL melting points such as polluted thermal areas or in situ treatment of plastic wastes which will be needed in the further estimation of the cost of processing.An extracellular lipase active on Ɛ-polycaprolactone was isolated after cultivation of


The proposed full BDI scheme flow is compatible with the main process flow of NS-GAA transistor fabrication and provides a large window for process fluctuations, such as the thickness of the S/D recess. It is an ingenious solution to insert the dielectric material under the source, drain and gate regions to remove the parasitic channel. Moreover, because the S/D-first scheme decreases the problem of high-quality S/D epitaxy, the innovative fabrication scheme introduces full BDI formation after S/D epitaxy to mitigate the difficulty of providing stress engineering in the full BDI formation before S/D epitaxy (Full BDI_First). The electrical performance of Full BDI_Last is demonstrated by a 4.78-fold increase in the drive current compared to Full BDI_First. Furthermore, compared to traditional punch through stoppers (PTSs), the proposed Full BDI_Last technology could potentially provide an improved short channel behavior and good immunity against parasitic gate capacitance in NS-GAA devices. For the assessed inverter ring oscillator (RO), applying the Full BDI_Last scheme allows the operating speed to be increased by 15.2% and 6.2% at the same power, or alternatively enables an 18.9% and 6.8% lower power consumption at the same speed compared with the PTS and Full BDI_First schemes, respectively. The observations confirm that the novel Full BDI_Last scheme incorporated into an NS-GAA device can be utilized to enable superior characteristics to benefit the performance of integrated circuits.In this paper, a novel scheme for source/drain-first (S/D-first) full bottom dielectric isolation (BDI), i.e., Full BDI_Last, with integration of a sacrificial Si According to Moore’s Law and Dennard’s Law, planar metal–oxide–semiconductor field-effect transistors (MOSFETs) should be scaled down over a long period of time. As the MOSFETs size shrinks, the short channel effect (SCE) becomes increasingly prominent, leading to the emergence of fin field-effect transistors (FinFETs). The FinFET structure, introduced in the 20 nm technology node to mitigate the side effects of the SCE in semiconductor devices, has been successfully applied to the 5 nm technology node. The fin channels have become thinner to improve the gate control capability, which becomes more severe as the size is further reduced. In addition, the height of the fins has gradually increased to allow for a larger effective width in the same area. However, these methods of strengthening FinFET structures are also approaching their limits. Thus, NS-GAA devices are some of the most promising candidates after FinFETs for 3 nm process nodes and for aggressive CMOS downscaling ,2,3,4 beIn addition to the areas mentioned above, NS-GAA transistors have a wider effective width in the same footprint, resulting in one of the unique features of NS-GAA transistors compared to FinFETs: the “fat-fin” effect. A fat fin is created by process non-idealities, causing an increased off-state leakage current in the bulk region below the bottom Si nanosheet. Sub-channel leakage is of great concern in scaled CMOS technologies and suppression of the parasitic channel in NS-GAA transistors is extremely challenging and much more complex than in FinFETs. There are various approaches being discussed to address this issue, including (i) a heavily doped substrate, which is referred to as a PTS module ,7,8, andIn a general PTS structure, a P-type heavily doped substrate for NMOSs and an N-type heavily doped substrate for PMOSs are adopted to form an ultra-thin depletion layer between the S/D and the heavily doped fat fin, thus minimizing the consumption of the length of the fat fin to inhibit sub-channel leakage. However, at the same time, this may lead to a band-to-band tunneling (BTBT) current from the drain to the substrate P-N junction ,12,13. IBDI modules, such as full BDI or partial BDI modules, are studied to reduce the off-state current and exhibit excellent electrical characteristics by blocking the bottom parasitic channel leakage path . In addiTo tackle the issues mentioned above, in this paper, we demonstrated a novel S/D-first full BDI scheme that introduces a total isolation layer underneath the S/D and gate regions. The innovative fabrication scheme proposes full BDI formation after S/D epitaxy to circumvent the difficulty of introducing stress engineering in the full BDI formation before S/D epitaxy. In addition, the proposed Full BDI_Last scheme flow is compatible with the main fabrication flow of the NS-GAA transistor fabrication and provides a large window for process fluctuations, such as the thickness of the S/D recess. Compared with PTS engineering, the proposed full BDI module shows the benefits of significantly suppressing the parasitic channel, reducing the capacitance of gate and optimizing the performance explained by using 3D-TCAD. Moreover, the effects of a PTS, Full BDI_First and Full BDI_Last fabricated by the novel scheme on the operating speed and power consumption characteristics of a basic inverter RO are simulated separately.−3 and the depth of the S/D recess was set to 5 nm, as shown in −3 and 5e18 cm−3 and an S/D recess depth of 5 nm, as shown in X-axis direction. To implement Full BDI_Last engineering, Si0.5Ge0.5 with high Ge concentration was epitaxially grown first as a sacrificial layer for full BDI before the three-layer stacked Si/Si0.7Ge0.3 was grown. One particular note is that the thickness of the sacrificial Si0.5Ge0.5 layer for full BDI was 15 nm to be below the critical thickness for plastic relaxation [0.5Ge0.5 layer for full BDI is higher compared to three-layer stacked Si0.7Ge0.3, it will etch faster when the inner spacer is prepared, forming a groove circled by the red box in 0.7Ge0.3 to Si0.5Ge0.5 can reach 1:1.5, which means that when the inner spacer is prepared to etch a 4 nm Si0.7Ge0.3 layer, the remaining thickness of the Si0.5Ge0.5 sacrificial layer at the bottom of the S/D will be at least 4 nm, which means the thickness of the BDI layer at the bottom of the S/D is at least 4 nm. The thickness of the BDI layer at the bottom of the gate remains at 15 nm. Then, a Si layer was epitaxially grown before the S/D epitaxial growth presented in 0.5Ge0.5 layer is removed in the subsequent steps. STI in the channel width direction was performed to etch down a bit  according to the high selective etch ratio (at least 1:20) of Si0.7Ge0.3 to Si0.5Ge0.5 [0.5Ge0.5 layer to form the full BDI structure. As shown in A simplified 3D process simulation has been carried out based on the Sentaurus Process TCAD tool to verify the feasibility of this innovative Full BDI_Last fabrication scheme, as shown in laxation , as show bit see e and a s0.5Ge0.5 . Figure Synopsys Sentaurus TCAD with advanced physical models  was usedThe calibration was conducted with key process parameters acquired from the experimental reports and the device’s geometrical dimensions were set according to SEM and TEM analysis information . Additio0.5Ge0.5 S/D region of Full BDI_First, leading to no compressive stress in the final Si nanosheet . In addition to a higher leakage current and other performance indicators, the parasitic sub-channel will contribute to an aggravated Cgg, which will reduce NS-GAA device performance. Circuit operation characteristics affect not only direct current (DC) I–V characteristics, but also alternating current (AC) C–V characteristics. The BSIM-CMG model library , which c0.5Ge0.5 layer underneath the S/D and gate region, aiming to inhibit parasitic channels in the Si substrate. After the S/D epitaxial growth, the bottom sacrificial Si0.5Ge0.5 layer was completely removed and filled with a dielectric material to form a full BDI structure. In particular, employing a Si layer as the etch stop layer to protect the SiGe S/D region in the P-type NS-GAA device was completely feasible during direct removal of the Si0.5Ge0.5 layer.In this work, the formation of a Full BDI_Last device and its electrical properties have been discussed based on Sentaurus TCAD simulations. Full BDI_Last was constructed by a novel fabrication flow combining the S/D-first scheme and introducing a sacrificial SiOn the one hand, the Full BDI_Last preparation process is compatible with the main fabrication flow of NS-GAA transistors. Most importantly, the Full BDI_Last module displayed great immunity to process volatilities such as the S/D recess and RDF due to a heavily doped PTS. Furthermore, the innovative process is beneficial for S/D epitaxial reinforced stress engineering because the S/D-first scheme provides a high-quality starting surface for S/D epitaxial growth compared with Full BDI_First. On the other hand, the full BDI module used in the NS-GAA device can potentially offer significant benefits over the PTS module. In terms of parasitic sub-channel leakage, the full BDI technique provides a solution for removing the parasitic sub-channel to control leakage and improves the electrical properties in all aspects, including reducing the parasitic capacitance compared to the PTS module. Moreover, it was verified that in an inverter RO, which is a logic circuit, it is possible to increase the speed by 15.2% and 6.2% under iso-power conditions and decrease the power by 18.9% and 6.8% under iso-speed conditions, compared to the PTS scheme and the Full BDI_First scheme, respectively. The novel full BDI scheme present in the NS-GAA device provides some guidance for the subsequent preparation of high-performance circuits.


Stress amidst the COVID-19 pandemic is becoming more prevalent. This paper aimed to describe the validation process of the Malay Perceived Stress Scale modified for COVID-19 (PSS-10-C) amongst Malaysian youths.n = 267) and Study 2 (n = 324), respectively.The cross-sectional validation study design was employed in this study. In Phase I, the scale was translated into Malay by using the forward-backward method. In Phase 2, principal axis factoring and confirmatory factor analysis were conducted in Study 1 (n = 324), the confirmatory factor analysis showed that the two-factor model achieved acceptable model fit indices, including χ2/df ratio = 2.57; root mean square error of approximation (RMSEA) = 0.07; 95% CI = 0.05, 0.09; Tucker-Lewis Index (TLI) = 0.95 and Normed Fit Index (NFI) = 0.94. The Cronbach’s alpha scale score was 0.855 for the study samples.A two-factor solution, comprising ‘distress’ and ‘coping’ domains was derived (cumulative variance = 65.2%) in Phase 2. Concurrent validity evaluated via the Beck Hopelessness Scale revealed a moderate positive correlation (0.528). In Study 2 (The Malay PSS-10-C is a valid and reliable scale to be used amongst Malaysian youths. The coronavirus disease COVID-19) pandemic (caused by the SARS-CoV-2 virus) is not only a threat to global health, but also has affected the mental well-being of many individuals 9 pandemi. This deIn Malaysia, the Prime Minister of Malaysia announced the Movement Control Order (MCO) on 18 March 2020 . Due to The COVID-19 pandemic has not only psychologically impacted individuals, but also has put a toll on the daily challenges faced by the general population . AmongstThe Perceived Stress Scale modified for COVID-19, or known as the COVID-19 Pandemic-Related Stress Scale (PSS-10-C) was adapted from the Perceived Stress Scale-10 (PSS-10). Cohen et al.  amid theTo date, a validated COVID-19-related stress scale in the Malay language is unavailable for stress level assessment in the Malaysian setting during and post-COVID-19 pandemic. A widely used scale in Malaysia, the Fear of COVID-19 Scale that was developed by Ahorsu et al.  and valiThis cross-sectional study conducted in Malaysia was to establish the validity and reliability of the Malay version of PSS-10-C within the Malaysian context. he flowchart for the translation and validation process of the English PSS-10-C into Malay PSS-10-C is shown in The PSS-10-C was modified by Pedrozo-Pupo et al.  from theTo translate the English PSS-10-C into Malay language, the forward-backward translation method was conducted by linguistic and subject matter experts. The subject-matter experts consisted of a counsellor who did the forward-translation into Malay language and a health psychologist who did the backward-translation into the English language. To ensure the face validity of this scale, a harmonisation meeting was held to combine the two versions of translated questionnaire and finalise the questionnaire. During the adaptation process to finalise the Malay version of scale, researchers considered the contextualised meaning attached to a construct, barriers in linguistics comprehension, and possible interpretations of the translated scale .This study involved Malaysian youths aged from 18 years old to 40 years old. For Study 1, participants were young adults who have recently graduated, were currently working or were looking for jobs. For Study 2, Malaysian students from local and private universities were recruited. Individuals were eligible for inclusion if they were Malaysians, aged between 18 years old and above, sufficiently literate in Bahasa Malaysia and able to provide an informed consent for the study. An additional inclusion criterion of being a university student enrolled in one of the tertiary education institutions in Malaysia was added for the participant recruitment in Study 2. Those unable or unwilling to provide an informed consent were excluded.For validation, the questionnaire was adhered to the rule of thumb in recruiting 2–20 participants per item –29 with Apart from the PSS-10-C, the Beck Hopelessness Scale (BHS) was used in Phase 2 of the study. The BHS was constructed by Beck et al.  as a selConvenience sampling was used to collect data and the online survey link was distributed through a variety of social media platforms and e-mail lists. Study 1 was carried out amongst non-student youths with the objective of validating the construct and concurrent validity of the scale. Study 2 was carried out amongst university students to further test the model fit of the factor structure obtained in Study 1. Participation in the study was voluntary and strictly confidential without any identifier being used in the questionnaire. All pertinent information concerning the study was written on the questionnaire, enabling participants get a comprehensive understanding concerning the study before voluntarily participated in the study. Since the questionnaire was distributed online, participants were afforded sufficient time to consider their participation and fill the questionnaire unrushed. Then, an informed consent was obtained from the participants before proceeding to the next part of the questionnaire. Participants were required to fill a set of questions which consisted of three main sections: i) demographic details including age, gender, race, monthly household income and educational level, ii) Malay version of PSS-10-C and iii) Malay version of BHS. The questionnaire took approximately 20 min and participants were free to withdraw from the study if any discomfort arose during the study.Statistical analyses were conducted by using the IBM SPSS Statistics for Windows, version 24.0  and the 2/df < 3.0)  , Normed f < 3.0) , parsimof < 3.0)  and rootTo examine internal consistency reliability of the scale, Cronbach’s alpha coefficient was employed. Items that contributed to Cronbach’s alpha of more than 0.70 were retained, whereas items that contributed to a low coefficient would be excluded from further analysis , 44. Then = 267 [45.2%]) and participants from Study 2 were university students (n = 324 [54.8%]). The demographic characteristics of the participants from Study 1 and Study 2 are reflected in A total of 591 participants responded to the questionnaire. Participants from Study 1 comprised non-student youths  and thus, supported the inclusion of each item in the factor analysis. All items had communalities ≥ 0.20 (range of 0.35–0.74)  was conducted. The minimum amount of data required for factor analysis was met, which was 26 cases per questionnaire item. Factorisation by using varimax rotation, revealed an acceptable Kaiser-Meyer-Olkin measure of sampling adequacy (KMO = 0.87), which was above the recommended value of 0.60. Bartlett’s test of sphericity was significant, χ2 = 1302.835–0.74) , suggestr (267) = 0.289, P < 0.001.PAF examined the solutions for one and two factors. The two-factor solution was preferred, as it explained a higher percentage of cumulative variance (65.2%) as compared to the one-factor solution (44.5%), which was more than the recommended cumulative variance of 60%. Factor 1  accounted for 44.5% of the variance and Factor 2  accounted for another 20.7% of the variance. All items had primary loadings of above 0.40 (range of 0.59–0.84) . The corr (267) = 0.528, P < 0.001.Concurrent validity was analysed by correlating PSS-10-C with the BHS. Results showed that the scales correlated significantly, 2/df ratio = 2.57, which was within the < 3.00 cut off suggested by Carmines and McIver  and relative (TLI and PNFI) fit indices. The χple data . In addiI = 0.91 . PerhapsFinally, this study showed that the Malay PSS-10-C demonstrated acceptable internal consistency reliability of Cronbach’s alpha ≥ 0.70 for the total scale as well as its domains. Apart from that, the scale was also reliable when tested amongst the non-student young adult and student samples of Study 1 and Study 2, demonstrating its reliability across the two groups. The results indicated that across the student and non-student youth samples, these items measured the same construct or content and was a reliable scale for use in the two groups. Therefore, the scale was a reliable instrument to be used in the Malaysian youth sample.This is the first study to adapt and validate a PSS-10-C amongst the Malaysian population. The scale was applicable to be used amongst students and non-student youths. However, the study results may not be representative of Malaysians as almost all respondents were from the Malay ethnic group. Besides that, the female-to-male ratio of respondents was not representative of the Malaysian population. The heterogeneity of respondents in this study was partially achieved, as respondents involved were youths from different occupational backgrounds. However, participants older than 40 years old were not sampled. Nevertheless, due to the brevity, reliability and validity of the Malay PSS-10-C, the scale would still be deemed useful in assessing individuals’ perceived stress related to COVID-19 pandemic in Malaysia. To make comprehensive comparisons and increase generalisability of the Malay PSS-10-C, studies in the future will need to employ different types of population and setting to further explore and improve the psychometric rigor of the scale.The Malay PSS-10-C scale demonstrated acceptable validity and reliability across student and non-student youth samples. The two-factor model achieved a cumulative explained variance of 65.2%. The two-factor solution of ‘distress’ and ‘coping’ domains demonstrated better model fit as compared to a one-factor solution, and was consistent with the original PSS-10-C scale and the Malay PSS-10 scale. Model fit indices indicated good model fit for both absolute and relative fit indices. Internal consistency reliability was acceptable for the summed scale score and across its two domains. Therefore, the Malay PSS-10-C is a valid and reliable instrument to be used amongst Malaysians to measure perceived stress as a result of the COVID-19 pandemic.